By Robert Davis, USA TODAY
BOSTON — When Bobby Lie's heart stopped and he fell to the floor of his downtown high-rise office, Mayor Thomas Menino saved his life. The mayor didn't rush to his side; a security guard did that. But emergency medical officials say Menino's leadership and his efforts to involve the community in saving lives changed the way Boston responds to such situations. Those changes saved Lie (pronounced LEE) and about 200 others over the past decade. Powerful, proactive city leadership can turn a sluggish emergency medical system into a highly effective one, a USA TODAY study shows. The 18-month investigation, which included a survey of medical directors in the nation's 50 biggest cities, database analyses and extensive interviews and site visits, shows most big-city EMS systems are fragmented and slow, and as a result they lose about 1,000 lives a year that could be saved. (Related graphic: How 50 cities stack up): But even an old city with complex problems can have a top-performing emergency medical system if city officials are forceful and committed. Boston is a case in point. The best test of an emergency medical system is how many "saveable" victims of sudden cardiac arrest it actually saves. These patients must be reached and shocked with a defibrillator within six minutes, or they almost always die. (Related video: Anyone can save a life) When Menino was elected mayor in 1993, Boston saved only 14% of these people. Menino was determined to improve that rate and make Boston's EMS among the nation's best. He tackled the system's performance on three fronts: He dealt with long-standing turf battles between the fire department and the ambulance crews; he hired a medical director to provide strong medical oversight to paramedics and insisted that EMS performance be measured meticulously; and he recruited the public's help. Now, Boston saves 40% of cardiac arrest victims, second among the nation's biggest cities after Seattle's 45%. The story of how Boston transformed itself is instructive, almost a manual that other big cities could follow to save more lives. Dealing with turf battles Boston has seen bitter disputes between firefighters and ambulance crews, the same kind of disputes that have undermined the emergency medical systems in major cities nationwide. At the highest level, the debate in Boston has been over whether the fire department should take over the ambulance system, as other big-city fire departments have done. But on the front lines, where feuds have raged for generations, the disagreements boiled over about smaller issues. "We had fistfights in the street" between firefighters and paramedics, Menino says. "There were real trust problems." He saw the conflict firsthand as a city councilman in the mid-1980s. Menino sometimes would ride in the back of the ambulances on busy nights to see what the crews faced on a typical shift. He was struck by the friction between the two services. One petty dispute, for instance, was over ambulance parking. Because ambulances carry intravenous fluids and medications that must be kept near room temperature, ambulance crews wanted to park their rigs inside the fire stations. Although the crews were not part of the fire department, they responded together to emergencies, so they had a relationship. But when fire department officers refused to allow some of the medics to park ambulances inside the firehouses, the ambulance crews were forced to run extension cords to heaters in the back of the rigs. "Some places the ambulance would be outside, and they'd give the poor paramedics just a tiny table inside and no place for them to clean up after a run," Menino says. That changed when he was elected mayor. "We found them space," he says. The city converted spaces from many agencies, including the department of public works and the police department and local hospitals, to move the rigs and the crews inside, out of the cold. Breaking down walls Change did not come easily, particularly for the firefighters' union. The union and Menino bumped heads on more than one occasion, and not just over emergency medical services. Menino found the union to be a powerful force. At one point in 2001 when the union and Menino were deadlocked over contract issues, firefighters protested outside the mayor's State of the City speech. Only one of the 13 city council members crossed the picket line to attend the speech. But eventually, Menino and the firefighters made their peace. And the mayor put a stop to the debate about whether the ambulance system would become part of the fire department. It would not. That decision went against a national trend in which fire departments have been taking over emergency medical services as the number of fire calls goes down and the number of medical emergencies goes up. Running more calls justifies more money, so Menino's decision to keep the two services separate in Boston has contributed to a steady decline in the number of firefighter jobs. At 1,600 firefighters, the department is at the lowest staffing level in 15 years, says Nick DiMarino, president of Boston Firefighters Local 718. Though DiMarino is quick to praise the mayor and says the fire department will "support what the mayor wants to do," he also says, "I would be lying if I said I'd like to keep it this way." Menino says that as long as he is mayor, the two agencies will remain separate, with the ambulance service an arm of the health department. Even so, the ambulance service works closely with the fire department. Firefighters carry defibrillators and respond to cardiac arrest calls, and often they are the first to reach and treat those victims. Though an undercurrent of conflict still exists, the partnership that has been struck with the mayor's support is saving lives. "The fire department first responders have greatly enhanced our cardiac arrest survival," says Peter Moyer, medical director of Boston fire, police and ambulance service. Strong medical oversight Like other major cities, Boston could not tell from its response-time measures how quickly crews were reaching and treating patients. The city knew how long it took for a rig to drive from a station to the scene, but the numbers did not tell how fast crews were providing care. So the city began to measure closely what is known as "call to shock" — the time that passes between the instant the call comes in that someone has collapsed in cardiac arrest, and the instant the first shock is delivered from a defibrillator. Measuring this time takes manpower and enough computer equipment so that no crew has to go out of service to have its data counted. Boston EMS had the backing of the mayor to spend the money it needed. The result was the same as it has been in other cities that have measured this time closely: More lives were saved almost immediately. By paying close attention to every case and looking at places where the system failed, the city found simple ways to reach victims faster. Sometimes it meant putting more defibrillators in public areas so security guards could grab them. In other cases, it meant better planning to get rescue units through security or past other delays more quickly. At the same time, Menino made sure that EMS had enough money for strong medical oversight. Moyer heads a team of six doctors who track the performance of medics and give them constant feedback on the care they are providing. The city pays six physicians $400,000 a year collectively to oversee the medical care given to more than 100,000 patients a year. Enlisting the public
When Boston looked closely at each response to a cardiac arrest, the city found that crews simply could not reach some victims within six minutes — the dividing line between life and death. Getting to the top floors of a high-rise, past the security at the city jail or to the back nine of a golf course ate up too much time. Boston officials took a look at how other cities reached higher survival rates. They found that Seattle, for one, measures how often someone already is performing CPR when emergency medical crews arrive. Over time, Seattle has learned that more victims of cardiac arrest survive if a bystander intervenes and performs CPR, buying the person time until a defibrillator can be applied. So Seattle's emergency medical system, called Medic One, pushes CPR training and makes citizens partners. The city has trained ordinary citizens — from taxi drivers to restaurant employees — in CPR, making them members of what is known as Medic Two. Seattle firefighters work as instructors for the program and teach about 18,000 people a year. Since 1971, the city has trained 650,000 people. As a result, Seattle now has one of the highest "bystander CPR" rates in the nation — 44%. That means that nearly half of all cardiac arrest victims get CPR from a co-worker, a loved one or a stranger in the minutes between collapse and when emergency medical crews arrive. "Seattle showed us it could be done," says Rich Serino, Boston's emergency medical services chief. So Boston launched its own effort to involve citizens in saving lives, offering CPR training to individuals, churches, clubs and anyone who requested it. Menino used his clout as mayor to help EMS forge a partnership with local businesses. The city asked businesses to prepare to react to a cardiac arrest on their premises by having a defibrillator on hand and by having people trained to use it and to perform CPR. As a result, Boston's bystander CPR rate is 30%; that is, bystanders are already performing CPR when rescue crews arrive 30% of the time. The city has saved an additional 200 lives over the past 10 years with a public training program conducted by the fire department that cost $65,000 last year and is expected to cost nothing next year. "It is extraordinarily rare to have a mayor who takes an interest in EMS like this mayor," says John Auerbach, executive director of Boston's Public Health Commission. And Serino says the mayor's support provided a protective cover under which dedicated people could work without interruption. "It's not an overnight success," Serino says. "It's a commitment. The idea of one-shot funding is OK for getting things started, but you have to make a long-term commitment, and that is what this mayor has done." Menino, who until last month served as the president of the U.S. Conference of Mayors, says every major city could turn its emergency system around "if they wanted to do it." "In government, we always find an excuse for why we don't do it. Very few people in government want to find out how we can do it. I'd rather figure out how we can do it and say, 'Why don't we have that program here?'." Businesses on board Among those businesses that are now prepared to act in emergencies is Fidelity Investments, where Lie is a senior vice president. On the day he collapsed last year, the lean and athletic 60-year-old executive had cut his daily workout short and taken a few spoonfuls of heartburn medicine, hoping that the pain near his heart would subside as he worked at his desk. When a co-worker heard the thud in his office, she found him on the floor in cardiac arrest. Co-workers started CPR immediately. A "Code 10" was announced over Fidelity security's radios, which told Sean Stanek, 28, who was just five floors away, that there was an emergency. Stanek, a "business security representative," as Fidelity calls its security guards, grabbed his medical bag, oxygen and defibrillator and raced upstairs as another member of his team called Boston EMS. Stanek had never done CPR on a person and had certainly never shocked anybody. But his basic CPR and defibrillator training from Boston EMS — and his experience from riding along with Boston ambulance crews — had prepared him for just such a crisis. "My head was just going back to all of my training, the basic steps," he says now. "Through repetition, it just gets ingrained in your head." The cocoon of people surrounding Lie's body opened as Stanek approached. He told a co-worker to unbutton the victim's shirt as he reached for his scissors to cut off the white T-shirt beneath. "The defibrillators are pretty easy to use," he says. "It read Bobby's heart rhythm and told me I needed to shock him. I shocked him once. Then it told me to start CPR, so I did." Within seconds, Boston EMS members were walking into the office. As the emergency crew rushed Lie to the hospital, Stanek was uneasy. "I was standing outside, and I was a little nervous," Stanek says. "Did I do this? Did I do that? What if something I did could have affected him for the worse? It was a little bit nerve-racking." Relief came hours later when his boss called to say Lie would be fine. Word spread, and Fidelity employees began signing up for CPR classes. The same thing has happened over the past 10 years in other Boston businesses. When a hotel security guard saved the life of a guest, other hotels called Boston EMS to join the program. Now workers in scores of businesses are part of Boston's emergency medical response. In a less organized way, businesses across the nation have launched similar programs. Sales of defibrillators to corporations rose 35% in 2001 as private companies bought 22,742 of the automated devices, according to an industry report by Frost & Sullivan. Still, most businesses have yet to get the equipment. Government statistics indicate 13% of all workplace deaths are caused by sudden cardiac arrest. But a study by market research company RoperASW and reported last month shows that only 6% of workplaces nationwide are equipped with portable defibrillators. And few companies are truly part of their city's emergency medical system. That's what sets Boston apart and keeps its emergency response seamless. Serino says the volunteers have become an army of lifesavers who now understand the strengths and weaknesses of the city's emergency medical system and are ready to fill in the gaps. They know that calling 911 and waiting for help can cost a life. And together, the city and the volunteers are better prepared to respond as a team. "In order to have a successful outcome, they have to be a partner," Serino says. "They are part of the solution." Boston's success could be repeated by other cities across the nation, says Charles Euchner, executive director of the Kennedy School's Rappaport Institute for Greater Boston at Harvard University. "There is no doubt cities can use this model," he says. "You give the resources and support for the people you are asking to carry the ball for you and then look at what the data show you. "If you get the building blocks right, then people will be able to take care of themselves better. Ultimately, city government creates circumstances where people can take care of themselves better." Contributing: Rati Bishnoi, Jacqueline Chong, Anthony DeBarros, Neal Engledow, Mary Grote, Erin Kirk, Jim Norman, In-Sung Yoo | |||||||||||||||
CPR keeps a heart quivering. Victims are more often found still in "V-fib" by medics when a bystander performs CPR.| | | |
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